Paraurethral
cyst, which presents as an cystic mass around the urethral meatus
is a rare congenital abnormality in the female newborn. Although the
reported incidence of the lesion is between 1 in 2000 and 1 in 7000
live female births, only 41 examples have been reported in literature.
Management of this lesion is controversial. Surgical excision has
been advocated but spontaneous rupture, aspiration or unroofing of
the cyst wall has also been reported. We present our experience in
the management of a case of paraurethral cyst in a newborn.
Introduction
Skene’s historic presentation in the 1880 established the clinical
significance of the periurethral ducts,1 obstruction of
which may lead to cyst formation at the urinary meatus, the paraurethral
cyst. Only 41 examples have been reported in literature, 37 of whom
presented in the newborn period.2 Herein we report our
experience in the management of a paraurethral cyst in a newborn girl
with a review of the pertinent literature.
Case Report
A 3 week old female newborn the product of a full term pregnancy and
normal vaginal delivery was admitted with us for a swelling at the
vaginal introitus, which was apparently increasing in size adding
to the apprehension of the parents. Clinical examination revealed
a 1 cm cystic mass on the anterior vaginal wall lateral to and displacing
the urethral meatus to the right. The mass ovoid in shape and whitish
in colour, with small vessels in the cyst wall. There was no obstruction
to urination and no palpable abdominal mass was felt. An infant feeding
tube could be passed easily into the urinary meatus. Routine laboratory
test and radiological examination were normal. We performed unroofing
of the cyst wall. Sterile milky white mucoid fluid was evacuated and
the excised cyst wall were lined with transitional epithelium consistent
with Skene’s duct cyst. The infant remains asymptomatic and
the cyst has not recurred.
Discussion
Vaginal cysts are not common particularly in the newborn. The histologic
appearance of the cyst epithelium identifies the embryological origin
as is discussed.
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Fig.
1 : Paraurethral cyst |
1. Mullerian duct
system : Most vaginal cyst are of mullerian duct origin, lined with
stratified squamous epithelium and originate anywhere in the proximal
four-fifths of the vagina.3
2. Mesonephric duct system : Cysts derived from persistent mesonephric
duct (Gartner’s) ducts are lined with cuboidal or low columnar
epithelium and do not secrete mucus.4
3. Urogenital sinus derivative (Skene’s duct) : Paraurethral
cysts arises from the periurethral glands and ducts that empty into
the female urethra and are rudimentary homologues of the prostate
there are between 6 and 30 paraurethral ducts as demonstrated by Huffman.5
The 2 largest ducts commonly are referred to as Skene’s ducts.1
Skene’s glands are well developed in the foetus and small child
and do not change noticeably with adolescene. They secrete a small
amount of mucoid material with sexual stimulation that serves to lubricate
the urethral meatus during coitus. Occasionally, duct obstruction
may lead to a cyst formation that presents around the urethral meatus.
The cause of ductal obstruction is not known; however, it may occur
secondary to inflammation.6 Dislocation of urothelium into
an adjacent area resulting in blocking of the Skene’s duct may
account for the development of paraurethral cysts.3
Only 41 cases of paraurethral cysts have been described till date,
37 of whom are in newborns.2 Only one case of bilateral
paraurethral cyst has been described.7 Skene’s duct is lined
with squamous epithelium but paraurethral may be lined with urothelium
of squamous epithelium.3,6-9 Paraurethral cysts are slightly
more common on the right side.2 All the cases were products
of full term gestation and uncomplicated deliveries without any other
genitourinary abnormality.6 Clinical manifestation are
almost nil, however displacement of the meatus, difficulty in micturition
or spraying of urinary stream may be seen.
There is no consensus on the treatment of paraurethral cysts. Cohen
first reported spontaneous rupture in a neonate10 and hence
a conservative approach was advocated, however the duration of conservative
management is not clear. Current experience suggests that spontaneous
rupture of the lesion in neonates is unlikely after 2 months of age
and hence surgical intervention in the form of needle aspiration,
marsupalisation or excision should be considered.2
References
1. Skene AJC. The anatomy and the pathology of two important glands
of the female urethra. Am J Obstet 1880; 13 : 265.
2. Ceylan H, Hayri BO, et al. Paraurethral cyst: Is conservative management
always appropriate? Eur J Pediatr Surg 2002; 12 : 212-4.
3. Kimbrough HM, Vaughan DE. Skenes duct cyst in a newborn: case report
and review of the literature. Jr of Urology 1977; 117 : 387-88.
4. Blackwell WJ, McElin TW. Vaginal cysts of mesonephric duct origin
(Gartner’s duct cysts) : report of 22 cases. Quart Bull Northwestern
Univ Med School 1955; 29 : 94.
5. Huffman JW. The detailed anatomy of the paraurethral lesions in
the adult female. 1948; 55 : 86.
6. Lee NH, Kim SY. Skene’s duct cysts in female newborns. Jr
of Pediatr Surg 1992; 27 : 15-7.
7. Gottesman JE, Sparkuhl A. Bilateral Skene’s duct cysts. J
Pediatr 1979; 94 : 945-6.
8. Phupong V, Aribarg A. Management of Skene’s duct cysts in
the newborn girl. BJU Int 2000; 86 : 562.
9. Bergner DM. Paraurethral cysts in the newborn. South Med J 1985;
78 : 749-50.
10. Cohen HJ, Klein MD, Laver MB. Cysts of the vagina in the newborn
infant. Am J Dis Child 1957; 94 : 322-4.
*Resident; **Lecturer;
Department of Paediatric Surgery, BJ Wadia Hospital for Children,
Parel, Mumbai - 400 012.
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